Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board

Abstract

Purpose Pain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU(IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management. Methods We conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst. Results Evidence-based methods to assess pain are the enlarged 0–10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0–10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs. Conclusions Relief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.

Palliative Care Professional Development for Critical Care Nurses: A Multicenter Program

“…3,4,8,46,47 Prior work emphasizes the importance of care provision by clinicians with expertise in palliative care, 47 yet palliative care consultation services cannot see all seriously ill ICU patients.…”

“…41-43 Some of our sites have expanded the IMPACT-ICU program to include participants from other disciplines. We hope that training of ICU clinicians, in conjunction with integration of palliative care processes into routine practice, 44 will influence aspects of palliative care that did not improve with our program, such as identification of uncontrolled symptoms.Our work is significant, considering the growing focus on ICU palliative care, [3][4][5][6][7][8][9][10][45][46][47] for which a number of models exist. 3,4,8,46,47 Prior work emphasizes the importance of care provision by clinicians with expertise in palliative care, 47 yet palliative care consultation services cannot see all seriously ill ICU patients.…”

Ensuring Breathing Comfort at the End of Life: The Integral Role of the Critical Care Nurse

“…Titrating to the patient's responses with a low-and-slow regimen is recommended. 3 Mechanical ventilation, invasive or noninvasive, is an effective means of treating dyspnea associated with respiratory failure. Yet, dying patients generally want to forgo mechanical ventilation.…”

“…2 Dyspnea is akin to suffocation and is one of the worst symptoms experienced by critically ill patients, including those who are receiving mechanical ventilation. 3,4 …”

Tasking the tailor to cut the coat: How to optimize individualized ICU-based palliative care?

“…While one large trial of an integrative ICU-based palliative care approach studied in 22 French ICUs was associated with significant decreases in family member anxiety, depression, and post-traumatic stress disorder levels [14], only a handful of ICU-based palliative care studies [15][16][17] have measured family-reported outcomes other than ''family satisfaction''. Moreover, ICU-based palliative care trials have thus far not measured truly patient-centered outcomes, such as symptom scores or quality of life [18].…”